Responsible Party Information (RP)

Patient Agreement

Limitation of Practice: Patient understands that the practice of F. Clarke Holmes, M.D. is limited to Sports Medicine and Orthopedics.

Patient Consent: Patient hereby gives consent, if needed, for drawing blood samples for diagnosis or in case of accidental puncture or exposure to medical personnel during my course of treatment either in the offices or in the hospital. These tests may include AIDS testing.

Privacy Policy

All patients have a right to review our Notice of Privacy Practices. Any employee of the practice can provide you a copy of the Notice of Privacy Practices. If you would like to restrict access or request modifications be made to your Personal Health Information, please request the required form from a member of our staff.


Collection Policy

Insurance Claims Filing

In all cases, the patient is responsible for payment of their account. As a courtesy, Impact Sports Medicine and Orthopedics, PLLC will file a claim to the patients insurance coverage.

Assignment and Release: Patient hereby authorizes and assigns applicable assigns applicable insurance benefits to be paid directly to the physician. Patient is financially responsible for non-covered services. Patient authorizes release of information necessary to process insurance claims. Patient authorizes photographs to be restricted for medical, educational or insurance purposes and information released to other practitioners in good faith effort for my medical care.

Medicare: Patient requests that payment of authorized Medicare benefits be made either to the patient or on the patient's behalf to Impact Sports Medicine and Orthpedics, PLLC and their associates for any services furnished the patient by that physician. Patient authorizes any holder of medical information about the patient to release to the Center for Medicare and Medicaid Services (CMS) or its agents any information needed to determine these benefits payable for related services. This form is not to be used by the patient for Medicare reimbursement.

Managed Care Plans and Referrals

Managed care plans (e.g. HMO's) require specialist and sub-specialists to obtain a referral number before the physician can see a patient. The patient is responsible for obtaining a referral number, not this office. Failure to have a referral number prior to service will result i reduced benefits by the managed care plan. Therefore, the patient is responsible for any balance not paid by the coverage plan.

Co-Payments

In all cases, the patient is responsible for making co-payments at the time of the patient visit in the form of cash or check. If a co-payment is not made at the time of the patients visit, Impact Sports Medicine and Orthopedics, PLLC reserves the right to require co-payment to be made prior to all future patient visits.

No-Shows/Late Cancellation Fee

No-shows and late cancellations are disruptive to a medical practice, and most importantly, oftenprevent other patients from being seen sooner. Thus, a $40 fee will be applied if the patient does not present for his/her scheduled appointment or does not cancel with 24 hours advance notice.

Maximum 30-Day Period for Unpaid Balances

Patient Balances are due 30 days after insurance coverage payment has been made. In the alternative, the patient must make acceptable payment arrangements by contacting the Billing Department at Impact Sports Medicine and Orthopedics, PLLC. Balances may be paid via cash,check, Visa, or MasterCard.

Unpaid Balances

If for any reason the patient cannot make scheduled payments, the patient must immediately contact the Office Manager at Impact Sports Medicine and Orthopedics, PLLC to make acceptable arrangements. Impact Sports Medicine and Orthopedics, PLLC reserves the right to refer all unpaid accounts to collection agencies. Any fees associated with collection, including collection agency contingency fees and court costs, will be added to the patient’s account balance. After accounts are place with collection agencies, all patient visits and procedures will be on a cash only basis.

Service Charge

Impact Sports Medicine and Orthopedics, PLLC reserves the right to assess a service charge, not to exceed $20 per month, to a patient account for any unpaid balance over 30 days after the insurance coverage has been paid. No service charges will be assessed to patient account where the patient has made payment arrangements with the Billing Department and payments are being made as agreed.

ALL QUESTIONS CONCERNING THESE POLICIES SHOULD BE DIRECTED TO THE ADMINISTRATOR

2011 Murphy Avenue, Suite 603
Nashville, TN 37203

1.   I authorize Impact Sports Medicine and Orthopedics, PLLC to:

2.   The purpose(s) for the use or disclosure is as follows:

3.   The type and amount of information to be used or disclosed is as follows:

to

4.   I understand that my health information may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment and alcohol abuse.

5.   I understand that I have a right to revoke this authorization at any time. I understand that, if I revoke this authorization, I must do so in writing and present my written revocation to the practice. I understand that my revocation will not apply to the extent that Impact Sports Medicine and Orthopedics, PLLC has taken in reliance on this authorization. I understand that my revocation will not apply if this authorization was obtained as a condition of obtaining insurance coverage and the law provides my insurer with the right to contest a claim under my policy or the policy itself. Unless otherwise revoked, this authorization will expire on the following date, even, or condition: _________________. If i fail to specify an expiration date, event, or condition, this authorization will expire in six months.

6.   I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. Impact Sports Medicine and Orthopedics, PLLC may not condition treatment or payment on my signing this authorization. I understand that if I authorize Impact Sports Medicine and Orthopedics, PLLC to disclose my health information, the health information may be subject to disclosure by the recipient and may no longer be protected by certain federal privacy regulations. If I have questions about disclosure of my health information, I can contact the Practice Administrator.

ALL BLANKS MUST BE COMPLETED

Medications (name, dosage, & frequency)

Surgeries (type and date)

Have you ever had or are currently having?

General Health                                                         Eyes                                                                            Neurologic

ENT

Respiratory

Blood Disorders

Bladder, Kidneys, Other Urologic

Skin

Psychologic

Bones, Muscles, Joints                                                                                                                                 Allergic / Immunologic

Gynecologic

Comments on "Yes" answers / Other Medical Problems